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CITY OF P UOT LAKES ( HEALTH INSU =INFORMATION AGE BASED-CURRENT POLICY AGE BASED-RENEWAL POLICY CURRENT EMPLOYEE'S CITY'S CURRENT EMPLOYEE'S CITY'S EMPLOYEE COVERAGE PREMIUM SHARE SHARE PREMIUM SHARE SHARE Council 1 No Coverage $ 300.00 $ 300.00 Employee 1 Employee/Children $ 743.00 $ 368.00 $ 375.00 $ 911.00 $ 536.00 $ 375.00 Council Employee/Child $ 369.00 $ 69.00 $ 300.00 $ 452.00 $ 152.00 $ 300.00 Employee 2 Employee $ 361.00 $ - $ 361.00 $ 433.00 $ 58.00 $ 375.00 Employee 3 No Coverage $ 375.00 $ 375.00 Employee 4 Family $ 574.00 $ 199.00 $ 375.00 $ 694.00 $ 319.00 $ 375.00 Employee 5 No Coverage $ 375.00 $ 375.00 Council 3 No Covera e $ 300.00 $ 300.00 Employee 6 Family $ 552.00 $ 177.00 $ 375.00 $ 648.00 $ 273.00 $ 375.00 Em to ee 7 Employee/Spouse $ 550.00 $ 175.00 $ 375.00 $ 682.00 $ 307.00 $ 375.00 Council 4 No Coverage $ 300.00 $ 300.00 Employee 8 No Coverage $ 375.00 $ 375.00 Employee 9 Employee/Spouse $ 411.00 $ 36.00 $ 375.00 $ 491.00 $ 116.00 $ 375.00 Employee 10 No Coverage $ 375.00 $ 375.00 Em to ee 11 No Coverage $ 375.00 $ 375.00 Council 5 No Coverage $ 300.00 $ 300.00 Employee 12 No Coverage $ 225.00 $ 225.00 Employee 13 Family $ 602.00 $ 227.00 $ 375.00 $ 742.00 $ 367.00 $ 375.00 Council 6 No Coverage $ 300.00 $ 300.00 Council 7 No Coverage $ 300.00 $ 300.00 Em to ee 14 Family $ 484.00 $ 109.00 $ 375.00 $ 783.00 $ 408.00 $ 375.00 MONTHLY TOTAL $ 4,646.00 $ 1,360.00 $ 7,186.00 $ 5,836.00 $ 2,536.00 $ 7,200.00 ANNUAL TOTAL $ 55,752.00 $ 16,320.00 $ 86,232.00 $ 70,032.00 $ 30,432.00 $ 86,400.00 SINGLE/FAMILY RATE-$375+85%/15% SINGLE/FAMILY-CITY PAYS SINGLE RATE SINGLE/FAMILY-CITY PAYS SINGLE+50% CURRENT EMPLOYEE'S CITY'S CURRENT EMPLOYEE'S CITY'S CURRENT EMPLOYEE'S CITY'S EMPLOYEE COVERAGE PREMIUM SHARE SHARE PREMIUM SHARE SHARE PREMIUM SHARE SHARE Council 1 No Coverage $ 300.00 $ 300.00 $ 300.00 Employee 1 Employee/Children $ 651.63 $ 41.49 $ 610.14 $ 651.63 $ 171.63 $ 480.00 $ 651.63 $ 85.82 $ 565.82 Council 2 Employee/Child $ 651.63 $ 41.49 $ 610.14 $ 651.63 $ 171.63 $ 480.00 $ 651.63 $ 85.82 $ 565.82 Employee 2 Employee $ 480.00 $ 15.75 $ 464.25 $ 480.00 $ - $ 480.00 $ 480.00 $ - $ 480.00 Employee 3 No Coverage $ 375.00 $ 375.00 $ 375.00 Employee 4 Family $ 651.63 $ 41.49 $ 610.14 $ 651.63 $ 171.63 $ 480.00 $ 651.63 $ 85.82 $ 565.82 Employee 5 No Coverage $ 375.00 $ 375.00 $ 375.00 Council 3 No Coverage $ 300.00 $ 300.00 $ 300.00 Employee 6 Family $ 651.63 $ 41.49 $ 610.14 $ 651.63 $ 171.63 $ 480.00 $ 651.63 $ 85.82 $ 565.82 Em to ee 7 Employee/Spouse $ 651.63 $ 41.49 $ 610.14 $ 651.63 $ 171.63 $ 480.00 $ 651.63 $ 85.82 $ 565.82 Council 4 No Coverage $ 300.00 $ 300.00 $ 300.00 Employee 8 No Coverage $ 375.00 $ 375.00 $ 375.00 Employee 9 Employee/Spouse $ 651.63 $ 41.49 $ 610.14 $ 651.63 $ 171.63 $ 480.00 $ 651.63 $ 85.82 $ 565.82 Employee 10 No Coverage $ 375.00 $ 375.00 $ 375.00 Em to ee 11 No Coverage $ 375.00 $ 375.00 $ 375.00 Council 5 No Coverage $ 300.00 $ 300.00 $ 300.00 Employee 12 No Coverage $ 225.00 $ 225.00 $ 225.00 Employee 13 Family $ 651.63 $ 41.49 $ 610.14 $ 651.63 $ 171.63 $ 480.00 $ 651.63 $ 85.82 $ 565.82 Council 6 No Coverage $ 300.00 $ 300.00 $ 300.00 Council 7 No Coverage $ 300.00 $ 300.00 $ 300.00 Employee 14 Family $ 651.63 $ 41.49 $ 610.14 $ 651.63 $ 171.63 $ 480.00 $ 651.63 $ 85.82 $ 565.82 MONTHLY TOTAL $ 5,693.04 1 $ 347.67 $ 9,245.37 $ 5,693.04 $ 1,373.04 $ 8,220.00 $ 5,693.04 $ 686.56 1 $ 8,906.56 ANNUAL TOTAL $ 68,316.48 $ 4,172.04 $ 110,944.44 $ 68,316.48 $ 16,476.48 $ 98,640.00 1 $ 68,316.48 $ 8,238.72 $ 106,878.72 Yearly Cost Remainder of 2004 Cost $ 24,544.00 1 $ 10,226.00 $ 12,240.00 1 $ 5,100.00 1 1 $ 20,478.00 $ 8,532.00